A stroke or cerebrovascular accidentIt is any alteration that occurs temporarily or permanently, in one or more areas of the human brain as a consequence of a disorder in the cerebral blood supply (Martínez-Vila et al., 2011).
Currently, in the scientific literature we find a wide variety of terms and concepts that refer to this type of disorders. The oldest term is stroke, which was used in a generalized way when an individual was affected by paralysis, however, it did not imply a specific cause (National Institute of Neurological Disorders and Stroke, 2015).
Among the most used terms, recently we can find: cerebrovascular disease (CVD), cerebrovascular disorder (CVD), cerebrovascular accident (CVA), or the generic use of the term stroke. These terms are generally used interchangeably. In the case of English, the term used to refer to cerebrovascular accidents is "stroke".
Article index
A cerebrovascular accident or disorder occurs when the blood supply to an area of the brain is suddenly interrupted or when a blood stroke occurs (National Institute of Neurological Disorders and Stroke, 2015).
The oxygen and glucose that circulate through our bloodstream are essential for the efficient functioning of our brain, since it does not accumulate its own energy reserves. In addition, the cerebral blood flow passes through the cerebral capillaries without coming into direct contact with the neuronal cells..
Under baseline conditions, the necessary cerebral blood perfusion is 52ml / min / 100g. Therefore, any reduction in blood supply below 30ml / min / 100g will seriously interfere with brain cell metabolism (León-Carrión, 1995; Balmesada, Barroso and Martín and León-Carrión, 2002).
When areas of the brain stop receiving oxygen (anoxia) and glucose due to inadequate blood flow or a massive inflow of blood, many of the brain cells will be seriously damaged and may die immediately (National Institute of Neurological Disorders and Stroke, 2015).
The most widespread classification of diseases or cerebrovascular accidents is based on their etiology, and is divided into two groups: cerebral ischemia and cerebral hemorrhage (Martínez-Vila et al., 2011).
The term ischemia refers to the interruption of the blood supply to the brain as a result of a blockage of a blood vessel (National Institute of Neurological Disorders and Stroke, 2015).
It is usually the most frequent type of stroke, ischemic attacks represent 80% of the total occurrence (National Institute of Neurological Disorders and Stroke, 2015).
Depending on the extension, we can find: focal ischemia (affects only a specific area) and global ischemia (which can simultaneously affect different areas), (Martínez-Vila et al., 2011).
In addition, depending on its duration we can distinguish:
The blood supply through the cerebral arteries can be interrupted by several causes:
Brain hemorrhages or hemorrhagic strokes represent between 15 and 20% of all strokes (Martínez-Vila et al., 2011).
When blood accesses intra- or extra-cerebral tissue, it will disturb both the normal blood supply and the neural chemical balance, both essential for brain function (National Institute of Neurological Disorders and Stroke, 2015).
Therefore, with the term cerebral hemorrhage we refer to blood spilling within the cranial cavity as a consequence of the rupture of a blood, arterial or venous vessel (Martínez-Vila et al., 2011).
There are different causes of the appearance of cerebral hemorrhage, among which we can highlight: arteriovenous malformations, ruptured aneurysms, hematological diseases and creneoencephalic trauma (León-Carrión, 1995).
Among these, one of the most common causes are aneurysms; It is the appearance of a weak or dilated area that will lead to the formation of a pocket in an arterial, venous or cardiac wall. These bags can weaken and break (León-Carrión, 1995).
On the other hand, a rupture of an arterial wall may also appear due to loss of elasticity due to the presence of plaque (arteriosclerosis) or due to hypertension (National Institute of Neurological Disorders and Stroke, 2015).
Among arteriovenous malformations, angiomas are a conglomeration of defective blood vessels and capillaries that have very thin walls that can also rupture (National Institute of Neurological Disorders and Stroke, 2015).
Depending on the place of appearance of the cerebral hemorrhage, we can distinguish several types: intracerebral, deep, lobar, cerebellar, brainstem, intraventricular and subarachnoid (Martínez-Vila et al., 2011).
Strokes usually come on suddenly. The National Institute of Neurologial Disorders and Stroke proposes a series of symptoms that appear acutely:
When these symptoms occur as a result of a stroke, urgent medical attention is essential. Identification of symptoms by the patient or close people will be essential.
When a patient accesses the emergency room presenting a stroke, the emergency and primary care services will be coordinated by activating the "Stroke Code", which will facilitate the diagnosis and the initiation of treatment (Martínez-Vila et al., 2011 ).
In some cases, it is possible the occurrence of the death of the individual in the acute phase, when a serious accident occurs, although it has been significantly reduced due to the increase in technical measures and the quality of medical care.
When the patient overcomes the complications, the severity of the sequelae will depend on a series of factors both related to the injury and to the patient, some of the most important being the location and extent of the injury (León-Carrión, 1995).
In general, recovery occurs in the first three months in 90% of cases, however there is no exact time criterion (Balmesada, Barroso and Martín and León-Carrión, 2002).
The National Institute of Neurological Disorders and Stroke (2015), highlights some of the probable sequelae:
The development of new diagnostic techniques and life support methods, among other factors, has allowed the exponential growth in the number of stroke survivors.
Currently, there are a wide variety of therapeutic interventions designed specifically for the treatment and prevention of stroke (Spanish Society of Neurology, 2006).
Thus, the classic treatment of stroke is based on both pharmacological therapy (anti-embolic agents, anticoagulants, etc.) and non-pharmacological therapy (physiotherapy, cognitive rehabilitation, occupational therapy, etc.) (Bragado Rivas and Cano-de la Cuerda, 2016 ).
However, this type of pathology continues to be one of the leading causes of disability in most industrialized countries, essentially due to the enormous medical complications and deficits secondary to its occurrence (Masjuán et al., 2016).
The specific treatment of stroke can be classified according to the time of intervention:
When signs and symptoms compatible with the occurrence of a cerebrovascular accident are detected, it is essential that the affected person go to the emergency services. Thus, in most hospitals, there are already different specialized protocols for the care of this type of neurological emergency.
Specifically, the “stroke code” is an extra and intra-hospital system that allows rapid identification of the pathology, medical notification and hospital transfer of the affected person to the reference hospital centers (Spanish Society of Neurology, 2006).
The essential objectives of all interventions launched in the acute phase are:
- Restore cerebral blood flow.
- Monitor the patient's vital signs.
- Avoid increasing brain injury.
- Avoid medical complications.
- Minimize the chances of cognitive and physical deficits.
- Avoid the possible occurrence of another stroke.
Thus, in the emergency phase, the most commonly used treatments include pharmacological and surgical therapies (National Institute of Neurological Disorders and Stroke, 2016):
Most of the drugs used in cerebrovascular accidents are administered in parallel to their occurrence or after it. Thus, some of the most common include:
- Thrombotic agents: they are used to prevent the formation of blood clots that can lodge in a primary or secondary blood vessel. These types of drugs, such as aspirin, control the ability of blood platelets to clot and, therefore, can reduce the likelihood of stroke recurrence. Other types of drugs used include clopidogrel and ticoplidine. They are generally administered in emergency rooms immediately.
- Anticoagulants: This type of medicine is responsible for reducing or increasing the clotting capacity of the blood. Some of the most widely used include heparin or warfarin. Specialists recommend the use of this type of drug within the first three hours of the emergency phase, specifically through intravenous administration..
- Thrombolytic agents: these drugs are effective in restoring cerebral blood flow, since they have the ability to dissolve blood clots, in the event that this was the etiological cause of the stroke. Generally, they are usually administered during the occurrence of the attack or in a period not exceeding 4 hours, after the initial presentation of the first signs and symptoms. One of the most used drugs in this case is tissue plasminogen activator (TPA),
- Neuroprotectors: the essential effect of this type of drug is the protection of brain tissue against secondary injuries resulting from the occurrence of a cerebrovascular attack. However, many of them are still in the experimental phase.
Surgical procedures can be used both for the control of a cerebrovascular accident in the acute phase, as well as for the repair of injuries secondary to it.
Some of the procedures most used in the emergency phase may include:
- Catheter: if the drugs administered intravenously or orally do not offer the expected results, it is possible to opt for the implantation of a catheter, that is, a thin and thin tube, inserted from an arterial branch located in the groin to reach the affected brain areas, where the drug release will occur.
- Embolectomy: a catheter is used to remove or remove a clot or thrombus lodged in a specific brain area.
- Decompressive craniotomy: In most cases, the occurrence of a stroke can cause cerebral edema and consequently an increase in intracranial pressure. Thus, the objective of this technique is to reduce pressure by opening a hole in the skull or removing a bone flap..
- Carotid endarectomy: The carotid arteries are accessed through several incisions at the neck level, to eliminate possible fatty plaques that occlude or block these blood vessels.
- Angioplasty and stent: In algioplasty, a balloon is inserted to expand a narrowed blood vessel through a catheter. While in the case of the use of the stent, a clipping is used to prevent bleeding from a blood vessel or arteriovenous malformation.
Once the crisis is controlled, the main medical complications have been resolved and, therefore, the patient's survival is assured, the rest of the therapeutic interventions are started.
This phase usually includes interventions from different areas and, in addition, to a large number of medical professionals. Although rehabilitative measures are usually designed based on the specific deficits observed in each patient, there are some common characteristics.
In almost all cases, rehabilitation usually begins in the initial phases, that is, after the acute phase, in the first days of hospitalization (Group for the Study of Cerebrovascular Diseases of the Spanish Neurology Society, 2003).
In the case of cerebrovascular accidents, health professionals recommend the design of an integrated and multidisciplinary rehabilitation program, characterized by physical and neuropsychological therapy, occupation, among others..
After the crisis, the recovery period should begin immediately, in the first hours (24-48h) with physical intervention through postural control or mobilization of paralyzed joints or limbs (Díaz Llopis and Moltó Jordá, 2016).
The fundamental objective of physical therapy is the recovery of lost skills: coordination of movements with hands and legs, complex motor activities, gait, etc. (Know Stroke, 2016).
Physical exercises usually include the repetition of motor acts, the use of affected limbs, immobilization of healthy or unaffected areas, or sensory stimulation (Know Stroke, 2016).
Neuropsychological rehabilitation programs are specifically designed, that is, they must be oriented towards working with the deficits and residual capacities that the patient presents.
Thus, with the aim of treating the most affected areas, which are usually related to orientation, attention or executive function, this intervention usually follows the following principles (Arango Lasprilla, 2006):
- Individualized cognitive rehabilitation.
- Joint work of the patient, therapist and family.
- Focused on the achievement of the relevant goals at a functional level for the person.
- Constant evaluation.
Thus, in the case of care, attention training strategies, environmental support or external aids are usually used. One of the most used programs is the Attention Process Training (APT) by Sohlberg and Mateer (1986) (Arango Lasprilla, 2006).
In the case of memory, the intervention will depend on the type of deficit, however, it essentially focuses on the use of compensatory strategies and the enhancement of residual capacities through techniques of repetition, memorization, revisulization, recognition, association, environmental adaptations, among others (Arango Lasprilla, 2006).
In addition, on many occasions patients may present significant deficits in the linguistic area, specifically problems for articulation or expression of language. Therefore, the intervention of a speech therapist and the development of an intervention program may be required (Arango Lasprilla, 2006).
Physical and cognitive alterations will significantly impair the performance of activities of daily living.
It is possible that the affected person has a high level of dependence and, therefore, requires the help of another person for personal hygiene, eating, dressing, sitting, walking, etc..
Thus, there are a wide variety of programs designed for relearning all these routine activities..
Apart from the classic approaches described above, many interventions are currently being developed that are showing beneficial effects in post-stroke rehabilitation.
Some of the newer approaches include virtual reality, mirror therapy or electrostimulation.
Virtual reality techniques are based on the generation of a perceptual reality in real time through a computer system or interface. Thus, through the creation of a fictitious scenario, the person can interact with it through the performance of different activities or tasks.
Normally, these intervention protocols usually last about 4 months, after which it has been possible to observe an improvement in the capacities and motor skills of those affected in the recovery phase.
Thus, it has been observed that virtual environments are capable of inducing neuroplasticity and, therefore, contributing to the functional recovery of people who have suffered a stroke.
Specifically, different experimental studies have reported improvements in the ability to walk, grasp or balance..
The process of metal practice or motor imagery, consists of making a movement at the mental level, that is, without physically executing it.
It has been discovered that through this process the activation of a good part of the musculature related to the physical execution of the imagined movement is induced..
Therefore, the activation of internal representations can increase muscle activation and, consequently, improve or stabilize movement..
The mirror technique or therapy consists, as its name indicates, in the placement of a mirror in a vertical plane in front of the affected individual..
Specifically, the patient must place the paralyzed or affected limb on the back side of the mirror and the healthy or unaffected limb in front, thus allowing the observation of its reflex..
The goal, therefore, is to create an optical illusion, the affected limb in motion. Thus, this technique is based on the principles of mental practice.
Different clinical reports have indicated that mirror therapy shows positive effects, especially in the recovery of motor functions and pain relief..
The transcranial magnetic stimulation (TMS) technique is one of the most widely used approaches in the area of electrostimulation in stroke.
EMT is a non-invasive technique that is based on the application of electrical pulses to the scalp, over the areas of affected nervous tissue..
The most recent research has shown that the application of this protocol is capable of improving motor deficits, aphasia and even hemineglect in people who have suffered a stroke..
Yet No Comments